Provider Demographics
NPI:1538188602
Name:HERBST, JONATHAN A (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:A
Last Name:HERBST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JONATHAN
Other - Middle Name:A
Other - Last Name:HERBST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:388 WESTCHESTER AVE
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-3650
Mailing Address - Country:US
Mailing Address - Phone:914-937-3999
Mailing Address - Fax:914-937-3968
Practice Address - Street 1:388 WESTCHESTER AVE
Practice Address - Street 2:SUITE 1C
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-3650
Practice Address - Country:US
Practice Address - Phone:914-937-3999
Practice Address - Fax:914-937-3968
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY231234OtherWORKMAN'S COMP
NY00872275Medicaid
NY46A872Medicare ID - Type Unspecified
NY231234OtherWORKMAN'S COMP